How Stigma Surrounding the Use of HIV Preexposure Prophylaxis ...

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for people at risk for HIV because of sexual behavior ... Healthcare Foundation president. Michael Weinstein.33,37 ..... participants in the San Francisco Demon-.

How Stigma Surrounding the Use of HIV Preexposure Prophylaxis Undermines Prevention and Pleasure: A Call to Destigmatize “Truvada Whores” Antiretroviral preexposure prophylaxis (PrEP; emtricitabine and tenofovir disoproxil fumarate [Truvada]) prevents HIV without penalizing sexual pleasure, and may even enhance pleasure (e.g., by reducingHIV-relatedanxiety). However, concern about sexual risk behavior increasing with PrEP use (risk compensation) and corresponding stereotypes of promiscuity may undermine PrEP’s preventive potential. In this commentary, we review literature on sexual behavior change accompanying PrEP use, discuss risk compensation concerns and the “Truvada whore”stereotype as PrEP barriers, question the appropriateness of restricting PrEP access because of risk compensation, and consider sexual pleasure as a benefit of PrEP, an acceptable motive for seeking PrEP, and a core element of health. It is essential for science to trump stereotypes and sexnegative messaging in guiding decision-making affecting PrEP access and uptake. (Am J Public Health. 2015;105: 1960–1964. doi:10.2105/ AJPH.2015.302816)

Sarah K. Calabrese, PhD, and Kristen Underhill, JD, DPhil

ORAL ANTIRETROVIRAL PREexposure prophylaxis (PrEP) has received increasing recognition as a promising prevention strategy for people at risk for HIV because of sexual behavior, injection drug use, or both.1---7 Currently approved by the US Food and Drug Administration in once-daily pill form (emtricitabine and tenofovir disoproxil fumarate [Truvada]),8 PrEP has been praised for its multiple advantages as an adjunct to existing prevention methods (e.g., condoms) or in lieu of no protection, including its high efficacy among adherent users,9,10 user-controlled and concealable administration,11,12 and potential to support conception among serodiscordant heterosexual couples.13 Sexual pleasure—in terms of physical sensation or subjective enjoyment of sex—is less commonly acknowledged as a potential benefit within public health commentary surrounding PrEP, and several scholarly and popular press articles have framed the desire to engage in condomless sex as a dangerous and unacceptable motive for PrEP use.14---16 Risk compensation, or increased HIV risk behavior because of a perceived decrease in susceptibility to HIV (also referred to as offsetting, behavioral disinhibition, and condom migration17---19), has been identified as a concern and potential deterrent to PrEP prescription among health care providers20---31 and a key consideration among policymakers, health officials, and

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other stakeholders.12,32,33 The term “Truvada whore,” coined in a popular opinion piece condemning PrEP as a gateway to unsafe behavior,34 captures the assumptions and negative sentiment associated with PrEP echoed by several public figures, including playwright and activist Larry Kramer,35 actor Zachary Quinto,36 and AIDS Healthcare Foundation president Michael Weinstein.33,37 To the extent that risk compensation fears bolster opposition to PrEP implementation, they pose a potential barrier to access for people who stand to benefit from PrEP. In light of continued controversy regarding the role of sexual pleasure in PrEP uptake, we aim here to briefly summarize the state of knowledge on sexual behavior change among PrEP users, to outline how concerns about user behavior (anticipation of sexual risk compensation) may limit access to PrEP regardless of actual behavior, to question increased risk behavior as grounds for restricting access to PrEP, and to recognize sexual pleasure as an underacknowledged benefit of PrEP and an acceptable incentive for—or consequence of—PrEP uptake.

SEXUAL BEHAVIOR CHANGE AND ACCESS TO PrEP The prevalence and extent of sexual behavior change among oral PrEP users is currently under study. To date, double-blinded

clinical trials and open-label studies have failed to yield substantive evidence of risk compensation occurring among participants.1---3,7,38---45 Many of these trials have even reported reduced risk-taking among participants over time, including reductions in risk associated with sexual behavior1---3,7,38,41,45 and injection drug use.2 Likewise, preliminary reports from demonstration project and hospital-based clinical settings have indicated sustained or improved use of risk reduction strategies in conjunction with PrEP use among the majority of patients.46,47 In addition, some participants in PrEP acceptability research have indicated that they or others may maintain or decrease their risk taking as a result of PrEP use,48---60 perhaps adopting what has been called a “preventionist identity.”41,61 By contrast, a small increase in condomless sex with nonprimary partners was noted in the openlabel extension of the Partners PrEP Study,44 increased condomless sex and participation in riskier sexual roles (e.g., receptive positioning during anal sex) have been documented among several PrEP users in demonstration project and hospital-based clinical settings,46,47 and some participants in PrEP acceptability studies have predicted that they or others may engage in riskier sexual activity while using PrEP.48---60,62---66 Although predicted behavior may differ from actual behavior,67

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the variability of behavioral intentions expressed within PrEP acceptability research in combination with the limited existing insight about actual behavior among real-world PrEP users underscores the need for future research to accurately describe patterns of sexual behavior change outside of trial settings,68 particularly in light of mathematical models that suggest that behavioral changes could affect PrEP’s population-level impact.69,70 Even in the absence of substantive behavioral evidence for sexual risk compensation occurring, anticipated increases in sexual risk behavior among PrEP users may operate as a barrier to access in several ways. First, anticipated sexual risk compensation could reduce willingness to prescribe PrEP among providers,20---24,30 and judgment of a patient’s likelihood of engaging in sexual risk compensation may vary systematically according to social characteristics such as race,22 leading to inequitable access. Second, potential PrEP users may recognize that providers, peers, and others associate PrEP with sexual risk taking,65,71 as communicated through labels such as “Truvada whore.” This may reduce their motivation to seek PrEP or to sustain PrEP use for fear of stigmatization.62,71 Third, internalization of these negative associations may skew individuals’ perceptions of their own eligibility or need for PrEP, making them less likely to pursue PrEP as a method of self-protection despite their actual candidacy for it.65 A recent study of men who have sex with men presenting for HIV testing in commercial sex venues found that although 80% qualified as appropriate PrEP candidates on the basis of their recent sexual histories (according to

Iniciativa Profilaxis Pre-Exposición [iPrEx] clinical trial enrollment criteria), 78% of this qualifying group did not believe their risk was sufficient to warrant PrEP use; “stigma associated with taking prophylactic medication” was cited as one factor that may have contributed to this misperception.72 Fourth, because increased risk taking would reduce the costeffectiveness of PrEP, anticipated sexual risk compensation could decrease support for insurance coverage and privately and publicly funded financial assistance programs, rendering PrEP prohibitively expensive for many potential users at an approximate annual medication cost of $17 000 per year.73 Although medication costs will likely decrease when a generic version of PrEP becomes available (e.g., because of Truvada patent expiration), the expense of PrEP medication combined with required laboratory and professional services will continue to put PrEP out of reach for many who could benefit.73 Sustained financial support from outside sources is therefore essential, and anticipated risk compensation could threaten the willingness of these sources to defray PrEP costs. It is notable that even theoretical models of risk compensation17,68,74,75 do not predict that increased risk taking will occur among all PrEP users. Instead, these models propose that individuals only increase their risk taking when they have the opportunity to do so and perceive meaningful value in doing so, such as fulfilling a motivation to increase their sexual pleasure or relationship satisfaction. This means that risk compensation will not occur among people who lack the opportunity or motivation to increase their sexual risk taking. For example, someone already

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engaging in exclusively condomless sex will not decrease his or her condom use. Likewise, individuals who already derive the maximum value from their decisions about sex with respect to sexual positioning, partner selection, frequency of sex, and number of partners are not predicted to increase their risk taking along these dimensions simply as a response to PrEP use. If increased sexual risk taking does occur in conjunction with PrEP use, using this behavior change as grounds to condemn, withhold, or obstruct access to PrEP is problematic for several reasons. Primary among these reasons is that the high degree of protection provided by PrEP when taken as prescribed likely outweighs the increased risk of HIV acquisition resulting from increased risk taking.76---78 Therefore, impeding access to PrEP could prevent a net reduction in HIV risk even for individuals who increase their sexual risk behavior. Realistically, the exact threshold at which an increase in risk behavior offsets the protection against HIV derived from PrEP will be indeterminable for most individuals. The change in HIV risk corresponding to behavioral changes accompanying PrEP use cannot be precisely quantified, as people may not know, remember, or accurately report behavioral and contextual nuances affecting transmission risk.79,80 Even if sexual behavior could be precisely documented, there is no clear formula for determining when an individual PrEP user’s increased risk behavior indeed tips the balance to the point of an overall increase in HIV risk. Moreover, there is no assurance that this imbalance would be sustained over time. Where incomplete adherence to PrEP may erode its protective benefit, the scientific

literature has already identified multiple ways to support patients in improving their adherence81 instead of discontinuing PrEP prescription. Withholding PrEP on the basis of an overall increase in risk taking at the population level (should one be observed) would also be inappropriate because such a behavioral trend could not be assumed to represent the behavior of any particular individual. Variability in anticipated behavior change within PrEP acceptability research study samples48---60 as well as variability in actual behavior change reported among participants in demonstration project and hospital-based clinical settings46,47 indicate diversity in individuals’ behavioral responses to taking PrEP even within specific sociodemographic categories or health care contexts. Withholding PrEP from an individual on the basis of collective behavior would unfairly penalize individuals for whom PrEP could be an important health resource. Finally, restricting PrEP access because of risk behavior change at either the individual or population level neglects the health values and priorities of an individual. The perceived benefits of PrEP may extend beyond physical dimensions of health to encompass outcomes such as decreased HIVrelated anxiety, a greater sense of control over one’s sexual health, and increased sexual pleasure.82 Individuals will differ in the weight they assign to each of these outcomes as they consider the costs and benefits of PrEP use.

PrEP IN THE CONTEXT OF SEXUAL PLEASURE AND HEALTH Contemporary conceptualizations of sexual health consider

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disease prevention, but also recognize sexual pleasure as an integral component of well-being.83,84 Use of PrEP offers the opportunity to advance the goals of HIV prevention and pleasure promotion simultaneously across the gender and sexual orientation spectrum. To date, most empirically supported methods for preventing the sexual transmission of HIV have come with a penalty to pleasure. For example, abstinence and seropositioning limit the range of activities through which sexual pleasure can be achieved. Mutual monogamy with a partner who has tested HIV-negative reduces the opportunity to experience pleasure from sexual relations with other partners. Condoms have been reported to hinder pleasure in terms of arousal, sensation, and intimacy.85---87 By contrast, PrEP imposes no such penalties to pleasure as a nonbarrier method that offers protection across multiple sexual partners, positions, and contexts for both men and women. Research linking the belief that condoms interfere with intimacy to a greater likelihood of taking PrEP88 suggests that potential users may value PrEP as a unique method of reducing risk without incurring the same cost to pleasure. In addition to circumventing the pleasure penalties associated with other methods of HIV prevention, PrEP has the potential to enhance pleasure. Whether used in conjunction with other prevention methods or as a sole prevention strategy, PrEP offers people a layer of protection that they would not otherwise have. The psychological benefit of a known reduction in HIV transmission risk could potentially reduce “HIV rumination” and anxiety during sex, enabling individuals to relax and more fully enjoy their sexual

experiences.46,50,62,63,67,89 In addition, PrEP may enhance pleasure for HIV-negative individuals who previously avoided riskier sexual positions (e.g., the receptive role during anal intercourse) or partnering with serodiscordant others (for fear of HIV acquisition) by empowering them to broaden their sexual repertoires and pool of eligible partners.46,89 People living with HIV may also derive pleasure from PrEP, indirectly. As suggested in a recent oped,90 individuals living with HIV who experience anxiety about transmitting HIV to HIV-negative partners during sex, or who avoid serodiscordant partnering altogether, may experience reduced anxiety during sex with an HIVnegative partner as a result of knowing that their sexual partner is less susceptible to HIV while taking PrEP.46,90 They may also benefit from increased opportunities for pleasure if PrEP makes them more willing to bridge the serostatus divide in selecting partners.90 Finally, for serodiscordant couples with fertility desires who wish to pursue natural conception, both partners may take comfort and derive more pleasure in doing so when the HIV-negative partner is protected by PrEP. According to the constitution of the World Health Organization, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.”91(p1) Sexual health is a core element of health, and the dual advantages to sexual health that PrEP offers as a strategy that both prevents disease and promotes pleasure ought to be celebrated. Sexual pleasure---related motivations for PrEP use may help to drive beneficial demand for PrEP and support sustained adherence,77 optimizing the margin of protection gained from PrEP. Ensuring that

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sex-negative messaging and moral appeals—as exemplified by the “Truvada whore” stereotype—do not overshadow science and cloud the judgment of medical providers, policymakers, insurers, and potential PrEP users is essential to ensuring access to PrEP and achieving maximum benefit from this valuable biomedical technology. j

About the Authors Sarah K. Calabrese is with the Yale School of Public Health, New Haven, CT. Kristen Underhill is with Yale Law School, New Haven. Both are affiliates of the Center for Interdisciplinary Research on AIDS at Yale University, New Haven. Correspondence should be sent to Sarah K. Calabrese, 135 College St, Suite 358, New Haven, CT 06510 (e-mail: [email protected] Reprints can be ordered at by clicking the “Reprints” link. This article was accepted June 12, 2015.

Contributors S. K. Calabrese led the writing of this article, with significant input from K. Underhill. Both authors contributed to its conceptual development.

Acknowledgments The authors were supported by awards K01MH103080, K01MH093273, and P30MH062294 from the National Institutes of Mental Health. Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.

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American Journal of Public Health | October 2015, Vol 105, No. 10

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